Advocacy group: Death at Booneville center result of negligence

John LyonArkansas News Bureau

Wednesday

Jan 27, 2016 at 1:13 PM

A spokeswoman for the state Department of Human Services said the agency is prohibited by federal law from releasing medical information about a resident but said the group’s report shows that staff members at the center rendered medical aid to the woman.

A resident of the Booneville Human Development Center died last year because staff members thought she was “faking” a seizure and initially ignored her, a report released Tuesday by the advocacy group Disability Rights Arkansas claims.

A spokeswoman for the state Department of Human Services said the agency is prohibited by federal law from releasing medical information about a resident but said the group’s report shows that staff members at the center rendered medical aid to the woman.

Disability Rights Arkansas identified the woman as “Jane” and said in the report that she was 24 years old, had been in the facility for seven years and had a history of seizure-like symptoms.

The group said it investigated Jane’s Feb. 26 death and learned that in December 2014, a psychiatrist diagnosed her with factitious disorder. Behaviors associated with the disorder include deceptively presenting oneself as ill, impaired or injured.

On Jan. 6, 2015, the written treatment plan for Jane was revised to include instructions such as, “Staff should ignore jerks and twitches and monitor these behaviors using peripheral vision (avoid watching her directly).”

On the night of Jane’s death, according to the report, she was in the center’s TV room at 7:30 p.m. when her body jerked, she fell out of her chair and her cereal spilled. A shift supervisor reported that she asked Jane to get back in her chair, and she did.

A few minutes later, the supervisor left the TV room briefly, and when she returned she found Jane on the floor, her body jerking. The supervisor said she asked Jane to get back in her chair, but Jane’s body continued jerking and she began to throw up, according to the report.

The supervisor reported Jane’s actions to a nurse at 7:39 p.m. In one statement, the supervisor said she told the nurse Jane was having a seizure, but in a second statement she said she told the nurse Jane was having a “pseudo seizure.”

The nurse told the supervisor she would be there in a few minutes. The supervisor said she wiped vomit from Jane’s face, made sure there was nothing in her mouth and rolled her onto her back.

At 7:42 p.m., the nurse arrived in the TV room. After first giving another patient medicine, she checked on Jane.

The nurse said she believed at the time that Jane was breathing because she felt Jane’s breath on her hand, but while she was talking to the supervisor about what happened, she realized Jane had stopped breathing. The nurse later came to suspect that Jane was already dead when she entered the room and that she was mistaken about feeling Jane’s breath, according to the report.

Staff members tried various means to revive Jane, including CPR and the use of a suction device, without success. She was transported from the center by ambulance at 8:20 p.m.and was pronounced dead at Mercy Hospital in Booneville at 9:14 p.m.

Disability Rights Arkansas concluded in its report that Jane died “as a result of the outdated and primitive responses to behaviors used at the Booneville HDC that dangerously combined with a lack of coordination in medical and behavioral care that left her, and continues to leave other residents, at risk of injury and death.”

DHS spokeswoman Amy Webb said in a statement Tuesday, “Every day, Booneville HDC employees work around-the-clock to ensure the safety and well-being of residents at that facility. We at DHS take the death of any resident seriously and a thorough review is conducted to identify any facility or staffing issues that may have contributed to the death.”

Webb said she could not legally discuss details of a specific resident’s death but said that in a case like the one described in the advocacy group’s report, “Booneville HDC staff would closely monitor residents with potential choking issues. If a resident collapsed, staff would make sure the airway was open, no obstructions were present, the resident was breathing and would call a nurse.”

“If a resident stops breathing, CPR would be administered immediately and continuously until such time that emergency medical personnel arrive. Staff also could use a portable suction device to attempt to clear the resident’s airway, if choking was suspected,” she said, adding that Disability Rights Arkansas’ report shows that those steps were taken.

“DRA has expressed a desire for the Booneville facility to be closed and has not responded to a week-old request by the new division director to meet and discuss the facility,” Webb said.

The advocacy group said it is working to arrange a meeting with DHS. It has released two previous reports critical of the Booneville Human Development Center.

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